Surgical Treatment of Orbital Blowout Fractures: Complications and Postoperative Care Patterns

Abstract

Orbital fractures are a common result of facial trauma. Sequelae and indications for repair include enophthalmos and/or diplopia from extraocular muscle entrapment. Alloplastic implant placement with careful release of periorbital fat and extraocular muscles can effectively restore extraocular movements, orbital integrity, and anatomic volume. However, rare but devastating complications such as retrobulbar hematoma (RBH) can occur after repair, which pose a risk of permanent vision loss if not addressed emergently. For this reason, some surgeons take the precaution of admitting patients for 24-hour postoperative vision checks, while others do not. The incidence of postoperative RBH has not been previously reported and existing data are limited to case reports. Our aim was to examine national trends in postoperative management and to report the incidence of immediate postoperative complications at our institution following orbital repair. A retrospective assessment of orbital blowout fractures was undertaken to assess immediate postoperative complications including RBH. Only patients treated by a senior surgeon in the Department of Otolaryngology were included in the review. In addition, we surveyed AO North America (AONA) Craniomaxillofacial faculty to assess current trends in postoperative management. There were 80 patients treated surgically for orbital blowout fractures over a 9.5-year period. Nearly all patients were observed overnight (74%) or longer (25%) due to other trauma. Average length of stay was 17 hours for those observed overnight. There was one (1.3%) patient with RBH, who was treated and recovered without sequelae. Results of the survey indicated that a majority (64%) of responders observe postoperative patients overnight. Twenty-nine percent of responders indicated that they send patients home the same day of surgery. Performance of more than 20 orbital repairs annually significantly increased the likelihood that faculty would manage patients on an outpatient basis postoperatively ( = 0.04). For orbital blowout fractures, the number of immediate postoperative complications at our institution is low. In addition, North American trends in postoperative management of orbital blowout fractures may suggest that selected patients can be managed on an outpatient basis, which would have a positive effect on conservation of diminishing healthcare resources.

Outpatient Surgical Management of Orbital Blowout Fractures

“…Outpatient management was significantly more common among those who performed 20 or more OBF repairs annually. 13 Other authors have also argued in support of outpatient repair, although this is not yet considered standard of care in all settings. 3,14 The rate of orbital fractures, and therefore the associated cost of surgical management, is on the rise.…”

“…In a recent study by Shew and colleagues, a survey of AO North America Craniomaxillofacial faculty revealed that out of 105 craniomaxillofacial surgeons, 29% send patients home on the same day of surgery. Outpatient management was significantly more common among those who performed 20 or more OBF repairs annually 13. Other authors have also argued in support of outpatient repair, although this is not yet considered standard of care in all settings 314…”

Patterns of Orbital Fractures Needing Surgical Reconstruction in a Large Tertiary Hospital in Northern India

“…Orbital fractures cause severe injuries like loss of vision and disfigurement of face, leading to lifelong morbidity. 2 In a study on pediatric ocular trauma reported, eye globe was involved in 76.7%. 3 In another study from 2001 to 2014, 15 pediatric patients were identified as having sustained an NOE fracture.…”

Gradual oculomotor training in blow-out orbital fracture reconstruction recovery

“…Complications of oculomotor training have been previously reported, including hemorrhage and suture rupture due to excessive activity. 19 All clinicians should carefully observe the patient during training. For patients with obvious lower eyelid subcutaneous or retrobulbar hemorrhage, eyelid or bulbar conjunctival edema, or difficulty in eyelid opening, the training should be suspended until bleeding subsides.…”